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Manobianco A, Enketan O, Grass R. Tibiotalocalcaneal arthrodesis with an intramedullary nail: The functional and clinical outcome of a challenging patient group and its comparison to a below knee amputation. Foot Ankle Surg 2024; 30:268-272. [PMID: 38199925 DOI: 10.1016/j.fas.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to fuse the ankle and subtalar joints to treat severe ankle and hindfoot disease. Patients often have multiple operations before a TTCA. A below knee amputation (BKA) has major physical and psychological impacts. Our aim is to investigate the outcomes of these treatments in salvage situations, with a focus on objective functional measurements and patient reported outcome measures (PROMs). METHODS 52 patients underwent TTCA with a retrograde intramedullary nail and contacted for clinical and functional assessments and compared to patients who underwent traumatic BKA. PROMS such as AOFAS score, SF-36 and foot function index (FFI), and objective functional outcome measures were used. RESULTS Of the 52 TTCA patients, 28 patients were recruited for follow-up. 35.7% of patients had postoperative complications. Mean postoperative AOFAS score was 63.9 ± 8.4 (range, 47-81), FFI 48.8 ± 15.8 (range, 22.2-75.2). 11 BKA patients (mean age 46.4 years) were included as control group. BKA patients scored higher than the TTCA patients on SF-36 physical functioning (p < 0.01) and SF-36 mental health (p < 0.05) subscales. The flat-surface functional tests (timed up and go test, 2-minute walk test, 10-meter walk test) showed significantly (p < 0.05) better outcomes for the BKA compared to TTCA. CONCLUSIONS A TTCA is a salvage procedure with high complication rates. Functional and psychometric results are reduced compared to the normal population. Patients after a BKA had significantly better scores on SF-36 functional and mental health subscales and better functional outcomes for flat ground activities compared to TTCA. Heterogeneity of the TTCA and BKA patient cohorts is a limitation of this study. With these results in mind, the outlook of a BKA is not necessarily a grim one. They may be used by surgeons to counsel patients preoperatively when managing complex ankle and hindfoot disease. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Alexander Manobianco
- Department of Orthopaedic Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
| | - Oliver Enketan
- Department of Orthopaedic Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia; University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus Dresden, Fletscherstr. 74, 01307 Dresden, Germany.
| | - René Grass
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus Dresden, Fletscherstr. 74, 01307 Dresden, Germany
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Vesely BD, Kipp J, Russell G, LeSavage L, Hoffler H, Medda AW, Scott AT. Predictive Factors of Postoperative Pain in Patients With Tibiotalocalcaneal Arthrodesis With an Intramedullary Nail: A Retrospective Review. J Foot Ankle Surg 2024:S1067-2516(24)00055-3. [PMID: 38494111 DOI: 10.1053/j.jfas.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/28/2024] [Accepted: 03/09/2024] [Indexed: 03/19/2024]
Abstract
Tibiotalocalcaneal arthrodesis has been shown in literature to have good results in regards to low complication rates and deformity correction. While previous studies have investigated functional outcomes and complication rates, no large-scale studies have looked at pain outcomes. The present study performed a retrospective review of 154 extremities to analyze how a patient's comorbidities and characteristics influence pain outcomes following a tibiotalocalcaneal arthrodesis. The present study found an average change of pain from 7.1 to 3.0 in at least a 6 month follow up. We found that a diagnosis of chronic pain and tobacco use had statistically significant less pain improvement compared to patients without chronic pain or current tobacco use. We determined no statistically significant difference in pain outcomes for patients with or without Charcot deformity. Lastly, we found that with older patients there was more pain improvement observed. We physicians can educate current tobacco users of the improved pain outcomes with tobacco cessation prior to surgery. We recommend a multidisciplinary approach for pain in patients with a pre-operative diagnosis of chronic pain and to educate patients on realistic postoperative pain outcomes.
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Affiliation(s)
- Bryanna D Vesely
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC.
| | - Jennifer Kipp
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Gregory Russell
- Senior Biostatistician, Wake Forest University School of Medicine
| | - Lindsay LeSavage
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Hayden Hoffler
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Ashleigh W Medda
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Aaron T Scott
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
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Rosemberg DL, Macedo RS, Sposeto RB, Sakaki MH, Godoy-Santos AL, Fernandes TD. Tibiotalocalcaneal Arthrodesis: A Retrospective Comparison Between Nails and Lateral Locking Plate Complications. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231157719. [PMID: 36911423 PMCID: PMC9996735 DOI: 10.1177/24730114231157719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Background Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications. Methods We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones. Results We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure. Conclusion No significant differences were found in the complication rates between the 2 implants. Level of Evidence Level V, Case series.
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Affiliation(s)
- Dov Lagus Rosemberg
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Rodrigo Sousa Macedo
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Rafael Barban Sposeto
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Marcos Hideyo Sakaki
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Alexandre Leme Godoy-Santos
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Tulio Diniz Fernandes
- Lab Prof Manilo Mario Marco Napoli, Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
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Tonogai I, Tsuruo Y, Sairyo K. Relationship Between the Lateral Plantar Artery and the Retrograde Intramedullary Nail During Tibiotalar and Subtalar Arthrodesis: A Fresh Cadaveric Study. Foot Ankle Spec 2022; 15:551-555. [PMID: 33430626 DOI: 10.1177/1938640020986684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis with retrograde intramedullary nailing has become established. Iatrogenic injury to the vasculature (eg, lateral plantar artery [LPA] pseudoaneurysm) during insertion of the nail has been reported. The aim of this study was to identify the safe zone that avoids injury to the LPA during TTC arthrodesis. METHODS The retrograde lateral curved nail entry point should be in line with the midpoint of the tibial medullary canal and the lateral column of the calcaneus. Enhanced 3-dimensional computed tomography scans of 26 fresh cadaveric feet were assessed. The closest distance between the LPA and the edge of the nail entry point was measured in the plantar view. RESULTS The closest mean distance between the LPA and the edge of the nail entry point was 6.7 mm for all 26 feet, 12.8 mm for 3 feet (11.5%) in which the LPA did not cross the medial wall of the calcaneus, 8.1 mm for 9 (34.1%) in which the point where the LPA crossed the medial wall of the calcaneus was anterior to the center of the nail entry point, and 4.2 mm for 14 (53.8%) feet in which this point was posterior to the center of the nail entry point. CONCLUSIONS Care should be taken to avoid the LPA during reaming at the nail entry point, especially when the point where the LPA crosses the medial wall of the calcaneus is posterior to the center of the nail entry point. LEVELS OF EVIDENCE IV, cadaveric study.
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Affiliation(s)
- Ichiro Tonogai
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yoshihiro Tsuruo
- Department of Anatomy and Cell Biology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Rich M, Nguyen H, Whitmer K, Clements JR. Safe Placement of Intramedullary Nail and Inter-Physician Variability in Guidewire Placement in Retrograde Tibiotalocalcaneal Fusions. J Foot Ankle Surg 2019; 58:231-235. [PMID: 30850095 DOI: 10.1053/j.jfas.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Indexed: 02/03/2023]
Abstract
Retrograde tibiotalocalcaneal arthrodesis is a salvage procedure for severe arthrosis and deformity of both the tibiotalar and subtalar joints and requires image-confirmed placement of a retrograde guidewire. The anatomical shape of the calcaneus creates a situation in which guidewire placement can be skewed on imaging based on the angle of either internal or external rotation. As a result, the aims of our study were to (1) determine the optimal angle(s) of rotation required to accurately depict guidewire placement on imaging and (2) evaluate and describe the effects angle of rotation has on physician assessment of guidewire placement. Using a C-arm x-ray, images of cadavers with both correctly and incorrectly placed guidewires were taken at 5° increments of internal and external rotation of the cadaveric lower extremity and assessed for accuracy of guidewire depiction. The images revealed that the correctly placed guidewire appeared displaced medially at angles of 35° and 40° of external rotation. Conversely, the incorrectly placed guidewire appeared to be correctly placed at between 10° and 40° of external rotation. These images were then disseminated to various physicians including orthopedic surgeons and podiatrists to determine the ability of physicians to correctly appreciate guidewire placement. Using the responses from 35 physicians, it was found that certain angles of internal and external rotation preclude physicians from correctly determining guidewire placement. We found, based on chi-square analysis, that we were able to reject our null hypothesis with a p value of <.001 leading to the conclusion that indeed angle of rotation and guidewire placement can lead to false depictions of guidewire placement. In conclusion, our study gave objective measurements to guide foot placement during tibiotalocalcaneal fusion to decrease the risk incorrectly depicted medial guidewire placement and subsequent incorrect intramedullary nail placement.
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Affiliation(s)
- Matthew Rich
- Resident, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Hoa Nguyen
- Resident, Department of Obstetrics and Gynecology, Virginia Tech School of Medicine Roanoke, VA
| | - Kelley Whitmer
- Musculoskeletal Radiologist, Department of Radiology, Virginia Tech School of Medicine, Roanoke, VA
| | - J Randolph Clements
- Associate Professor of Orthopaedic Surgery, Virginia Tech School of Medicine, Roanoke, VA; Program Director, Podiatric Medicine and Surgery Residency, Carilion Clinic, Roanoke, VA.
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Angers-Goulet M, Beauchamp-Chalifour P, Laflamme N, Bouchard M, Laflamme M. Risk Factors for Removal of Calcaneus Screws: A Retrospective Study. J Foot Ankle Surg 2018; 57:701-706. [PMID: 29703456 DOI: 10.1053/j.jfas.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 02/03/2023]
Abstract
Although techniques using calcaneus screws have shown high union rates, posterior heel pain due to prominent hardware at the posterior and plantar aspect of the calcaneal tuberosity seems to be a significant complaint that often leads to hardware removal. The purpose of the present study was to identify the clinical and radiologic risk factors associated with calcaneus screw removal. A retrospective study of adult patients who required calcaneus screw fixation from January 2008 to December 2016 was conducted. We reviewed the medical records and radiographs to evaluate the risk factors for screw removal. Of the 123 patients included in the present study, 63 were male and 60 were female. The mean age was 55.0 ± 6.0 years, and the mean body mass index was 31.0 ± 6.0 kg/m2. The removal rate was 8.8% (10 of 114 evaluated) at the 1-year follow-up point and 13.6% (12 of 88 evaluated) at the 2-year follow-up point. The mean interval to removal was 1.23 ± 1.22 years. A total of 16 screws (72.7%) were removed for heel pain. At the 1-year follow-up examination, the removal rate due to inflammatory arthritis was 25.0% (p = .07). Moreover, the proportion of screw removal was greater at 2 years in illicit drug users (p = .008). Screw sizes ≤6.5 mm showed a tendency (p = .12) toward a lower rate of removal at the 2-year follow-up point. Calcaneus screws should be used with caution in specific patient populations such as illicit drug users and those with inflammatory arthritis. The use of smaller diameter calcaneus screws might be an option to lower the rate of screw removal due to heel pain.
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Affiliation(s)
- Mathieu Angers-Goulet
- Orthopaedic Resident, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada
| | | | - Nathalie Laflamme
- Epidemiologist, Centre de recherche CHU de Québec-Université Laval, Québec, QC, Canada
| | - Marc Bouchard
- Clinical Professor, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada
| | - Mélissa Laflamme
- Clinical Professor, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada.
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Shah AB, Jones C, Elattar O, Naranje SM. Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation. J Foot Ankle Surg 2017; 56:692-696. [PMID: 28476401 DOI: 10.1053/j.jfas.2017.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Indexed: 02/03/2023]
Abstract
Tibiotalocalcaneal arthrodesis (TTCA) is a well-established operative procedure for different severe pathologic conditions of the ankle and hindfoot joints. We present our results with a modified technique of TTCA using an intramedullary fibular strut graft in a series of complex cases of patients treated for multiple etiologies shown to have improved union rates. The technique involves inserting the fibular strut graft intramedullary after joint preparation and the use of either a Taylor spatial frame or plate and screws for definitive fixation. We reviewed the records of 16 patients who had undergone TTCA with this technique at our hospital from September 2013 to April 2015. Sixteen patients (10 males [62.5%] and 6 females [37.5%]) were included in the present study. These patients had complex cases and multiple risk factors, including diabetes, smoking, poor bone stock, and a history of previous surgeries. The mean follow-up time was 9.1 (range 9 to 18) months. Thirteen patients (81.2%) subsequently achieved union. The mean visual analog scale scores at the final follow-up examination had improved from 6.9 to 1.2. We suggest that our technique of TTCA with intramedullary fibular strut graft with fixation is a reasonable option to salvage complex cases with risk factors for operative complications.
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Affiliation(s)
- Ashish B Shah
- Assistant Professor of Surgery, Division of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL.
| | - Caleb Jones
- Medical Student and Research Assistant, Division of Orthopedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Osama Elattar
- Research Fellow, Foot and Ankle Surgery, Division of Orthopedic Surgery, University of Alabama at Birmingham, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Sameer M Naranje
- Attending Orthopedic Surgeon, Forrest City Medical Center, Forrest City, AR
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Abstract
Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and for the management of severe planar deformities of the ankle and hindfoot. Although the procedure results in a rigid ankle and hindfoot, it is often the only means of providing patients with a stable and painless foot and ankle for ambulation. Some patients who require the procedure have substantial bone loss that can be managed with a variety of autograft and allograft options. Options for tibiotalocalcaneal fixation include both internal and external devices, the selection of which depends on the underlying pathology, amount of bone loss, and type of bone graft selected. Relatively high complication rates associated with tibiotalocalcaneal fusion have been reported, with complications ranging from superficial infection to ultimate amputation; however, proper patient selection and careful graft and fixation planning can minimize the postoperative complications of the procedure.
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